What is the recommended dosage and administration of colchicine for treating gout pain?

How to Prescribe Colchicine for Gout Pain

For acute gout flares, prescribe colchicine 1.2 mg at the first sign of symptoms, followed by 0.6 mg one hour later (total 1.8 mg), then continue 0.6 mg once or twice daily until the attack resolves—but only if treatment starts within 36 hours of symptom onset. 1, 2, 3

Critical Timing Window

• Start treatment within 36 hours of symptom onset—colchicine effectiveness drops dramatically beyond this timeframe and should not be used for late-presenting flares 1, 2, 4, 3
• Ideally initiate within 12 hours for maximum efficacy 1
• Consider a "pill in the pocket" approach for well-informed patients to self-medicate at the first warning symptoms 1

Acute Treatment Dosing Algorithm

Initial Loading Dose:

• Give 1.2 mg (two 0.6 mg tablets) immediately at first sign of flare 1, 2, 3
• Follow with 0.6 mg (one tablet) exactly one hour later 1, 2, 3
• Total loading dose = 1.8 mg over one hour 1, 2, 4

Continuation Phase:

• Wait 12 hours after the loading doses 1, 2
• Resume 0.6 mg once or twice daily (maximum 1.2 mg/day) until the attack completely resolves 1, 2, 3
• Typically continue for several days until symptoms resolve 1

If Patient Already on Prophylactic Colchicine:

• Give the full loading dose (1.2 mg followed by 0.6 mg one hour later) 1, 3
• Wait 12 hours, then resume the regular prophylactic dose 1, 3

Evidence Supporting Low-Dose Regimen

• The AGREE trial demonstrated that low-dose colchicine (1.8 mg total) is equally effective as high-dose colchicine (4.8 mg) for pain reduction at 24 hours, with a number needed to treat of 5 for achieving 50% or greater pain reduction 1
• High-dose regimens provide no additional benefit but substantially increase gastrointestinal toxicity (diarrhea, nausea, vomiting) with a number needed to harm of 2 1, 5
• The older regimen of 0.5 mg every 2 hours until relief or toxicity is obsolete and causes severe diarrhea in most patients 1

Absolute Contraindications

Do NOT prescribe colchicine if:

• Patient is taking strong CYP3A4 or P-glycoprotein inhibitors (clarithromycin, erythromycin, cyclosporine, ketoconazole, itraconazole, ritonavir, atazanavir, indinavir) 1, 2, 4, 3
• Severe renal impairment (eGFR <30 mL/min) 1, 2, 4
• Patient has both renal/hepatic impairment AND is taking potent CYP3A4 or P-glycoprotein inhibitors 1, 3

Dose Adjustments for Renal Impairment

Mild to Moderate Renal Impairment (eGFR 30-80 mL/min):

• No dose adjustment needed for acute treatment 4, 3
• Monitor closely for adverse effects 3

Severe Renal Impairment (eGFR <30 mL/min but not on dialysis):

• Use standard loading dose (1.2 mg followed by 0.6 mg one hour later) 2, 3
• Do NOT repeat treatment course for at least 2 weeks 2, 3
• Consider alternative therapy for recurrent flares 3

Dialysis Patients:

• Give only 0.6 mg as a single dose 2, 3
• Do NOT repeat for at least 2 weeks 2, 3

Dose Adjustments for Drug Interactions

Moderate CYP3A4 Inhibitors (diltiazem, verapamil, fluconazole, grapefruit juice):

• Reduce acute treatment to 0.6 mg × 1 dose, followed by 0.3 mg one hour later 3
• Do not repeat for at least 3 days 3

Strong CYP3A4 Inhibitors:

• Colchicine is contraindicated—do not use 1, 2, 4, 3

Alternative Treatments When Colchicine Cannot Be Used

First-Line Alternatives:

• NSAIDs at full FDA-approved doses (naproxen, indomethacin, or sulindac) until complete resolution 1, 4
• Oral corticosteroids: prednisone 30-35 mg/day for 3-5 days, or 0.5 mg/kg/day for 5-10 days then taper 1, 4
• Intra-articular corticosteroid injection for monoarticular or oligoarticular involvement 1, 4

Combination Therapy:

• For severe attacks involving multiple large joints or polyarticular arthritis, consider initial combination therapy with colchicine AND NSAIDs for synergistic anti-inflammatory effects 1

Common Pitfalls to Avoid

• Never use high-dose colchicine regimens (>1.8 mg in first hour)—they provide no additional benefit but cause severe gastrointestinal toxicity 1, 5
• Never prescribe colchicine for flares presenting >36 hours after onset—it will be ineffective 1, 2, 4, 3
• Never combine colchicine with strong CYP3A4/P-gp inhibitors—this can cause fatal colchicine toxicity 1, 2, 4, 3
• Never use colchicine for pain from other causes—it is not an analgesic medication 3
• Always screen for drug interactions before prescribing, particularly with macrolide antibiotics, antifungals, and HIV protease inhibitors 1, 2, 4, 3

Prophylaxis Dosing (When Initiating Urate-Lowering Therapy)

• Start colchicine 0.6 mg once or twice daily (maximum 1.2 mg/day) with or just prior to initiating urate-lowering therapy 1, 2, 3
• Continue for at least 6 months, or 3 months after achieving target serum urate if no tophi present, or 6 months after achieving target if tophi present 1, 2, 4
• This prevents the increased flare rate that occurs when mobilizing urate from tissue deposits 1, 2, 3